FLAT FEET – PES PLANUS

What exactly is a “flat foot”?

When you stand, most people have a “space” under the arch or instep of the foot, however the depth of space under the arch can be variable. You may notice in young children that their feet often look a little flat, this is usually totally normal as the arch tends to develop in their feet by of 9 or 10 years old.

Is it normal? 

In many people if the flat foot has been present since teenage years it may simply be the way their foot is shaped and entirely normal. In these cases both feet are often the same. There are many “foot specialists” who may tell you that your arches have “fallen”. It is important that any such advice is given to you by a suitably qualified professional who can tell what is normal from abnormal. Having a longstanding flat foot can be ok.

How do I know if my flat foot is normal or abnormal?

If only one foot is affected it may be abnormal. If your foot is painful and you think it is flat then it is possible you have something causing the flat foot. People often complain of this discomfort on exercise. If your foot shape changes over time (months) i.e. if you had normal arches and then the foot flattens then there is likely an abnormality. Rarely, from childhood you may have had quite a stiff foot, which as you develop into adulthood can become increasingly painful. This could be an abnormally flat foot. 

How do I know whether my flat feet are a problem?

You should see your family doctor and ask for a referral to a foot and ankle specialist if:

  • you are in pain (even if it is a small amount of pain). It is important to remember that flat feet can cause pain elsewhere in your body, due to poor gait and your weight being loaded unevenly up through your body with each step. If you have flat feet and are experiencing knee pain, back pain or headaches, it is important to consider whether your foot structure is contributing to pain.
  • your foot feels stiff or hypermobile;
  • you wear out shoes very quickly;
  • your feet seem weak.

 

What causes abnormally Flat Feet? 

  • Tarsal coalition, a childhood condition that is an abnormal fusing of some foot bones which makes the foot stiffer and quite flat
  • Tibialis posterior Tendon dysfunction. This is a large ankle tendon that can degenerate causing it to stretch and cease working correctly. It can be unexplained in many patients, in others it can be a build up of minor injuries.
  • Excessive laxity in the joints and this can be related to weight gain
  • Foot arthritis, arthritis in the back or middle of the foot is usually painful. It can be caused by an injury or develop with no real explanation.

What are the symptoms?

People may find walking painful especially along the inside border of the foot and ankle. Running can be very difficult due to pain. They can also get swelling in the inside of the ankle. Sometimes tingling or numbness can develop on the inside or sole of the foot because the nerve along the inside of the ankle may be slightly stretched or compressed.

How is the condition diagnosed?

The diagnosis is based on an accurate history or story of symptoms from the patient. Examining the foot for pain and swelling can differentiate a normal and abnormal flat foot. X-Rays can display the overall shape of the flat foot. They can also diagnose arthritis as a feature of the flat foot. An MRI scan is useful to determine whether the tendon is working normally and also if there are any abnormal bony fusions.

Can the problem get worse?

Unfortunately yes it can. If the cause is a simple tendon abnormality causing the foot to flatten then it can be helped with insoles and physiotherapy as the arch can be restored fairly easily. If the foot is left untreated then the foot can become arthritic and the flat foot can be quite stiff and impossible to correct with insoles. It is vital to get assessed as soon as possible as solutions to your problem can change a lot and become more difficult over time.

Different stages of flat feet

Problems related to flat feet are classified into different stages and these stages define what sort of treatment can be carried out.

Stage one

There is inflammation of the tendon but no obvious deformity. Diagnosis is made during a physical examination and confirmed by ultrasound or MRI.

Stage two

The severity of the flat foot is increasingly evident but it is not stiff or arthritic.

Stage three

The condition is increasingly painful and has lead to stiffness and arthritis in the hind foot.

Stage four

The arthritis has spread to the ankle joint.

 

How do you treat Flat feet?

If the foot is flat but flexible then you may be able to have treatment with simple insoles and physiotherapy. The idea is to support your foot to stop it getting worse but unfortunately the arch would be permanently flat without the insoles. For a more active person this treatment may not be satisfactory. In this case surgery to re-create the arch can be performed, a flat foot correction.

Will I need surgery for flat feet?

Surgery is sometimes required if the condition is more severe. The following procedures may be considered:

The calcaneal osteotomy

Sometimes known as the ‘heel shift’, this procedure involves moving the calcaneam, the large bone at the back of the heel which is out of alignment, correctly re- positioning it and then securing the bone using screws. At LFAC, we can sometimes, where appropriate, carry out this procedure in a minimally invasive way.

A tendon transfer

This is considered if the tibialis posterior tendon is severely damaged. A tendon is taken from one of the lesser toes, which is then transferred to run behind the medial malleolus. This does not affect the function of the toes and patients make a full recovery.

Fusion

At the final stages (stage 3 and stage 4) of adult flat foot, the fusion of joints needs to be considered in order to effectively eliminate pain.

Deciding whether surgery is necessary

Many patients are simply seeking advice on managing a problem. If you have an abnormal flat foot it will never be made “a normal shape in a normal shoe” without surgery. You can manage it with special insoles and physiotherapy but it can still get worse. Specially made shoes can be an attractive option, if your lifestyle is less active than others. Surgery is successful in over 80% of patients and worth discussing with your surgeon.

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